drug treatment systems in western balkan countries · candidate countries to the eu in the western...

Outcomes of a joint EMCDDA-UNODC survey of drug treatment facilities

Drug treatment systems in the Western Balkans

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Luxembourg: Publications Office of the European Union, 2019

Print ISBN 978-92-9497-366-5 doi:10.2810/150380 TD-06-18-248-EN-C

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© European Monitoring Centre for Drugs and Drug Addiction, 2019

Reproduction is authorised provided the source is acknowledged.

Recommended citation:

European Monitoring Centre for Drugs and Drug Addiction and United Nations Office on Drugs and Crime (2019), Drug

treatment systems in the Western Balkans: outcomes of a joint EMCDDA-UNODC survey of drug treatment facilities,

Publications Office of the European Union, Luxembourg.

Printed by Publications Office in Luxembourg

4 Acknowledgements

5 Introduction

5 Background

6 The aims of the facility surveys in the Western Balkan region

8 Methods

10 Albania

10 Overview of the treatment system in Albania

10 Findings from the 2017 treatment facility survey using the EFSQ in Albania

14 Conclusions and implications

15 Bosnia and Herzegovina

15 Overview of the treatment system in Bosnia and Herzegovina

15 Findings from the 2017 treatment facility survey using the EFSQ in Bosnia and

Herzegovina


21 Kosovo*

21 Overview of the treatment system in Kosovo

22 Findings from the 2017 treatment facility survey using the EFSQ in Kosovo


25 Serbia

25 Overview of the treatment system in Serbia

26 Findings from the 2017 treatment facility survey (WHO-UNODC Substance use

disorder treatment facility survey)


31 Discussion and way forward

33 References

I Contents

* This designation is without prejudice to positions on status, and is in line with UNSCR 1244 and the ICJ Opinion on the Kosovo declaration of independence. It applies to all mentions of Kosovo in this publication.

Authors: Alessandro Pirona and Sandrine Sleiman (EMCDDA) and Anja Busse and

Milos Stojanovic (UNODC)


4

Acknowledgements

EMCDDA: Paul Griffiths, Jane Mounteney, Andre Noor, Cécile Martel, Dagmar Hedrich,

Linda Montanari, Bruno Guarita, Anna Wcislo, Ilze Jekabsone, Gonçalo Felgueiras e Sousa,

Inês Hasselberg and Nicola Singleton

UNODC: Gilberto Gerra, Giovanna Campello, Elizabeth Saenz, Jan-Christopher Gumm,

Bojan Milosavljevic, Aleksa Filipov and Mahanam Mithun

WHO: Nicolas Clark

ResAd: Tomas Zabransky, Viktor Mravcik, Barbara Janikova, Katerina Skarupova

Albania: Ervin Toçi, Andi Shkurti, Arjan Bregu, Genc Burazeri,the Ministry of Health of

Albania and the Institute of Public Health of Albania

Bosnia and Herzegovina: Visnja Banjac, Nera Zivlak-Radulovic, Senada Tahirović, Sabina

Sahman, Dubravko Vanicek, the Ministry of Security of Bosnia and Herzegovina, the Ministry

of Civil Affairs of Bosnia and Herzegovina, the Ministry of Health of Bosnia and Herzegovina,

the Institute of Public Health of the Federation of Bosnia and Herzegovina, the Ministry of

Health and Social Welfare of Bosnia and Herzegovina, the Psychiatry Clinic at the University

Clinical Centre of the Republic of Srpska and the Public Institute for Addiction Disorders of

the Canton of Sarajevo

Kosovo: Lindor Bexheti, Kushtrim Krasniqi, Naim Muja, the non-governmental organisation

Labyrinth and the Ministry of Internal Affairs of Kosovo

Serbia: Jelena Jankovic, Aleksandra Dickov, Mirjana Jovanovic, the Centre for Monitoring

Drugs and Drug Addiction of the Ministry of Health of Government of Serbia, the Republic

Expert Commission for the Prevention and Control of Drug Use and Bojan Milosavljevic

(UNODC PO Serbia)

The data collection for this publication has been mostly undertaken with the financial

assistance of the EMCDDA-IPA5 project CT-2015/361-979.


5

Introduction

Background

This report presents a complex picture of the achievements

and challenges of drug treatment systems in the Western

Balkans, a politically defined region comprising the Balkan

states yet to become members of the European Union (EU):

Albania, Bosnia and Herzegovina, Serbia and the territory of

Kosovo.

The region has experienced considerable political and

social change since the early 1990s as a result of the

break-up of the Socialist Federal Republic of Yugoslavia.

This period has been marked by a shift towards the

independence of most former Yugoslav republics, which

has entailed political reconstruction, armed conflicts,

intraregional migration and the displacement of large

populations through a process that is not yet fully

consolidated. A transition of such scale, and the challenges

that the region has experienced as a result, can generate

structural conditions conducive to a high-risk environment

in the context of illicit drug use. This is true in particular

with regard to drug use disorders and related health and

social consequences.

Furthermore, one of the most established international

distribution routes for illicit drugs, the ‘Balkan route’,

which links Afghanistan to the large markets of Russia and

western Europe, passes through the Western Balkans.

It is a particularly important route not only for the heroin

trade but also for cocaine and cannabis (EMCDDA and

Europol, 2016; UNODC, 2018a). As far as responses to the

drug phenomenon are concerned, alignment with the EU

has brought new challenges related to the transposition

of the EU acquis into the countries’ national legislation,

especially in the area of justice and home affairs. However,

it has also created new opportunities for cooperation and

for discussions on approaches addressing illicit drug use,

associated health and social harms, and responses. This

report is an example of such collaboration, presenting the

outcomes of joint work between the European Monitoring

Centre for Drugs and Drug Addiction (EMCDDA), the United

Nations Office on Drugs and Crime (UNODC), the World

Health Organization (WHO) and the Western Balkan states

to obtain an updated overview of the countries’ national

drug treatment systems.

The EMCDDA works with EU Member States to develop

a comprehensive drug monitoring framework. It monitors

developments in the EU drug situation through a variety of

methods, including a set of key epidemiological indicators

and data collection on the provision of, access to and the

availability of drug treatment in EU Member States, as well

as on drug markets and supply. Over the past decade, the

EMCDDA has expanded and consolidated its cooperation

with national drug authorities in candidate and potential

candidate countries to the EU in the Western Balkan

states — Albania, Bosnia and Herzegovina, the former

Yugoslav Republic of Macedonia, Montenegro, Serbia and

the territory of Kosovo. This collaboration aims to align the

drug monitoring systems of these countries and Kosovo

with the comprehensive EU drug monitoring framework.

This has been possible owing to funding made available

to the EMCDDA through the Community Assistance for

Reconstruction, Development and Stabilisation programme

and the Instrument for Pre-Accession Assistance (IPA),

under which several consecutive projects have been

carried out since 2008. The work to support the region in

further consolidating their drug information systems and

producing reliable data on the current drug situation is

continuing under the EMCDDA IPA 6 project ‘Stepwise

integration of the IPA beneficiaries in the activities of the

EMCDDA activities and the REITOX network’, initiated in

July 2017.

The UNODC collects, analyses and reports data on

the extent of, patterns in and trends in drug use and

its health consequences through the Annual Report

Questionnaire (ARQ) (UNODC, 2018b). The data collected

through the ARQ enable the monitoring of and biennial

reporting to the Commission on Narcotic Drugs (CND)

on the implementation by Member States of the Political

Declaration and Plan of Action on International Cooperation

towards an Integrated and Balanced Strategy to Counter

the World Drug Problem. In addition, the UNODC supports

the UN Member States in their efforts to set up, improve

and maintain effective data collection systems on drug

use and service planning, with a view to reducing drug

demand. It does this through global, regional and national

projects, such as the UNODC-WHO Programme on Drug

Dependence Treatment and Care (UNODC, 2018c).

Since 2010, the UNODC in collaboration with the WHO

has provided technical assistance to the region of South

Eastern Europe in five countries — Albania, Bosnia and

Herzegovina, the former Yugoslav Republic of Macedonia,

Montenegro, and Serbia — in collaboration with the


6

relevant ministries. This initiative has been carried out

through the Programme on Drug Dependence Treatment

and Care (GLOK32). The project aims to promote policies

that strike the right balance in terms of reducing drug

supply and demand, and incorporate science-based drug

prevention and dependence treatment.

The aims of the facility surveys in the Western Balkan region

The situation regarding the provision of treatment for drug

use disorders within the Western Balkan region is variable.

Past studies have indicated that, in general within the

region, there is a combination of state programmes and

services provided by non-governmental organisations

(NGOs), frequently with the support of international

donors and regional networks (EMCDDA, 2015). Specialist

drug treatment services, both in- and outpatient, are

largely linked to psychiatric hospitals, and, except in

Serbia, little or no drug treatment is provided through

general practice clinics. The availability of specialist drug

treatment interventions is particularly limited in Albania

and Kosovo, where there is a single, government-supported

specialist drug treatment centre, supplemented by NGO

services. However, the introduction or scaling up of opioid

substitution treatment (OST) constitutes one of the

most notable achievements documented in the Western

Balkans in the past 10 years. In 2012, Kosovo introduced

OST, with the financial support of the Global Fund to Fight

AIDS, Tuberculosis and Malaria. Founded in 2002, the

Global Fund is a partnership between governments, civil

society, the private sector and people affected by AIDS,

tuberculosis and malaria. The Global Fund is the world’s

largest financier of AIDS, TB, and malaria prevention,

treatment and care programs. In the Western Balkan

region, it has been one of the main external funding

sources for developing national capacities to deliver

evidence-based services, such as voluntary counselling

and testing, needle and syringe programmes, OST, and the

promotion of treatment for hepatitis C infection for people

who inject drugs. Since 2003, the Global Fund has signed

13 grant agreements in the Western Balkans and more

than EUR 100 million has been committed to support the

provision of HIV prevention services to vulnerable groups,

including people who inject drugs. However, the Global

Fund’s financial support to harm reduction operations has

been, or is about to be, discontinued in most countries

in this region, and the prospects for sustaining current

services and their quality remain unclear.

Data on treatment provision in the region remain patchy.

The data that are available are not yet fully comparable

and the coverage of national monitoring systems remains

partial in most of the countries. Nonetheless, information

about the characteristics, capacity, performance and quality

of national treatment systems and specific parts thereof is

required to plan treatment provision and commissioning,

and to identify access barriers and support investment

decisions. Regular standardised client monitoring and

surveying of drug treatment facilities are therefore important

to determine if key policy objectives are being met, that is,

to answer questions such as ‘Do people have adequate

access to treatment?’ ‘What treatments are offered?’ and

‘Are these treatments evidence-based and cost-efficient?’

To support governments in the region to meet these

policy information needs and to complement the available

treatment-related data collected through standard

monitoring systems, a pilot survey of treatment facilities

providing services to individuals with substance-related

problems was carried out by the EMCDDA with experts in

Albania, Bosnia and Herzegovina, and Kosovo in 2017. The

pilot survey relied on nationally adapted versions of the

European Facility Survey Questionnaire (EFSQ) (EMCDDA,

2017a) and was supported financially by the EMCDDA

IPA 5 project ‘Preparation of the IPA beneficiaries for their

participation in the European Monitoring Centre for Drugs

and Drug Addiction’ (EMCDDA, 2017b). In addition, the

UNODC and WHO supported the government of Serbia in

conducting a facility survey in Serbia, also in 2017, using

the WHO-UNODC mapping tool, which is a drug treatment

facility survey questionnaire that is, to a large extent,

compatible with the EFSQ.

The main aim of these national facility surveys was

to collect information from drug treatment providers

across national addiction treatment systems on their

characteristics, client utilisation, staffing, quality

management and the availability of interventions, while

accounting for their diversity.

This report provides a summary of the key findings from the

drug treatment facility surveys carried out in 2017 in the

Western Balkans, as well as conclusions and implications

for practice and policy.

It should be noted that the comparability of the results

between populations is limited because of the differences

in design and methodology between the relevant studies

(see Chapter 2). Therefore, data from each survey

are presented in individual chapters. Each chapter

comprises four main elements. At the beginning, some

key information on the most recent data on the drug

situation is presented, followed by a short overview of the


7

national treatment system in the country in question. The

information presented in these overviews refers to data

from 2015 or earlier, drawn from national reports and drug

overviews produced by the governmental authorities and

published on the EMCDDA website (EMCDDA, 2018a).

The overviews also include tables concerning the networks

of outpatient and inpatient treatment facilities. Data

presented in these tables were produced by experts during

a workshop on treatment system mapping in 2016 and

refer to the data collection year 2015.

The third part addresses the main focus of this report and

presents a summary of the key findings from the treatment

facility surveys carried out in 2017 in Albania, Bosnia and

Herzegovina, and the territory of Kosovo, and in 2016-17 in

Serbia. The data presented in this section relate to services

and clients at the facilities during a pre-defined reference

period from January 2016 to December 2016 in Albania,

Bosnia and Herzegovina, and the territory of Kosovo and in

Serbia.

The final section provides concluding remarks as well as

considering possible implications for practice and policy

at national level, based on reports produced by the experts

using the findings from the treatment facility surveys and

their knowledge of the situation.


8

MethodsTo support the implementation of the facility surveys, the

EMCDDA organised two technical workshops, in collaboration

with the UNODC, under the framework of the IPA 5 project.

The first took place in Lisbon in December 2016 and the

second in Tirana in May 2017. Both workshops were attended

by representatives of Albania, Bosnia and Herzegovina,

Serbia, the territory of Kosovo and the UNODC. In addition,

external experts from the Czech Republic were contracted to

provide methodological support. During the workshops, the

participants discussed sampling and data collection methods,

as well as the adaptation of the questionnaires to address

national characteristics and information needs.

Two different, but to a large extent compatible, survey

questionnaires were used: the EFSQ in Albania, Bosnia and

Herzegovina, and the territory of Kosovo, and the WHO-

UNODC Substance use disorder treatment facility survey

(UNODC and WHO, 2018) in Serbia. The WHO-UNODC survey

was developed as part of the UNODC-WHO Programme on

Drug Dependence Treatment and Care for the purpose of

mapping the substance use disorder treatment services in

a given country (UNODC, 2018d). The WHO-UNODC survey

questionnaire consists of five sections: treatment facility

contact details for survey correspondence; treatment facility

contact details for the general public; description of the

treatment facility and treatment offered; number of people

treated; and treatment capacity (buildings and staff). The data

provided in response to this questionnaire can be used for

several purposes. The survey’s aim is to collect information on

the scope of treatment services provided, and consolidated

data on the number of treatment clients, available human

resources and the facilities’ structural resources. The data

may be used to map services in a country or region, to develop

a register for the general public, for research (in consolidated

form) or as a basis for treatment availability, accessibility

and quality monitoring. The facility survey, together with

the International Standards for the Treatment of Drug Use

Disorders (UNODC and WHO, 2016), the Treatment Demand

Indicator (TDI) and the UNODC Treatment Quality Assurance

Tool, forms part of a basic suggested package for treatment

planning and monitoring.

The EFSQ is a data collection instrument applicable in

any country interested in surveying facilities that provide

interventions to drug users. It consists of five sections:

administrative characteristics (Section A); client utilisation

(Section B); staffing and quality management (Section C);

core interventions (Section D); and a glossary of terms used

in the questionnaire (Section E). A manual on how to carry out

a survey of drug treatment facilities using the EFSQ, as well

as an electronic version of the EFSQ for a web-based survey

using the open source survey software LimeSurvey, can be

found on the EMCDDA website (EMCDDA, 2017a). For the

facility surveys carried out in Albania, Bosnia and Herzegovina,

and the territory of Kosovo with the EFSQ, three additional

questions on the budgets (total budget, funding sources and

share of the total budget by each funding source) of the units

(facilities) were added. The EFSQ was translated into the

national languages by the EMCDDA and the national versions

were checked and pre-tested. This step is described in the

relevant chapters of this report.

The sampling unit of the survey is a service unit. A unit is

defined as a separate, stand-alone organisational entity (a

medical centre, a department, a programme, etc.) that has its

own defined objectives, procedures, rules and scope of services

and interventions, its own target group(s), and a team and

manager (team leader). How exactly a unit is defined depends

on the parent organisation or the responsible manager and its

organisational structure, but each unit should be reported on as

one of the main provider types defined by the EMCDDA in the

EFSQ (Table 1).

If the parent organisation or facility operates several units that

meet the criteria for the target unit, each distinct unit should

complete the survey. If the unit provides multiple types of

services, the type of unit is selected in accordance with the

services that the unit primarily provides (typically determined

by number of clients).

Taking into account the regional similarities of treatment

systems in the Western Balkans, it was decided that the coding

of types of services into the EFSQ standardised categories

would be harmonised as shown in Table 1.

The sampling frame, that is, the list of drug service providers

to be addressed, was prepared by experts nominated

by their governments to work with the EMCDDA and the

UNODC on this project, in collaboration with the relevant

governmental authorities and ministries. The list was to

consist of all institutions potentially providing services to

individuals with substance-related problems. Participation

in the survey was contingent on a positive response to

the following question, which was the first question in the

survey and acted as a filter for participation: ‘Do you provide

addiction treatment, counselling or other services to clients/

patients with addiction problems (at least one person in

previous 12 months with problems with use of tobacco

and/or alcohol and/or illicit drugs and/or gambling)?’ If

the answer to this question was negative, the respondent

was redirected to the end of the questionnaire without

being asked to fill out the survey. If the answer was positive,


9

TABLE 2

Overview of the design and data collection process of the facility surveys in the Western Balkans

Type of programme Albania Bosnia and Herzegovina Kosovo Serbia

Instrument EFSQ EFSQ EFSQ WHO-UNODC facility survey questionnaire

Number of facilities addressed

41 71 6 53

Number of units included in the sample

10 55 5 39

Type of institutions addressed

Public, private, NGOs Public, NGOs Public, NGOs Public, private, NGOs

Time of data collection February to May 2017 March to May 2017 February to May 2017 October to December 2017

Reference period for the total number of clients in treatment (by primary substance and for OST clients)

January to December 2016




Data collection mode Electronic version of the questionnaire sent by email or post

Electronic or paper-based versions of the questionnaire sent by email or post

Electronic version of the questionnaire sent by email

Online questionnaire and questionnaire in Microsoft Word document sent by email or by post

TABLE 1

Types of facilities included in the various EFSQ categories

Typology of treatment facilities used in the EMCDDA data collection system and the EFSQ

Types of facilities in the Western Balkans corresponding to the EMCDDA-EFSQ categories

Outpatient units

Specialised outpatient treatment unit OST centres

Outpatient addiction treatment centres in psychiatric hospitals/clinics/departments

Any other specialised outpatient centre for substance users

Low-threshold unit Typically drop-in centres

General mental healthcare unit Community mental health centres

Outpatient psychiatric centres in psychiatric hospitals/clinics/departments

General (primary) healthcare unit Primary health centres, family doctors

Other outpatient unit (specify) Social outpatient counselling units, for example

Inpatient units

Hospital-based residential treatment unit �� Addiction treatment departments

�� Psychiatric wards in general or specialised hospitals psychiatric hospitals

Non-hospital-based residential treatment unit �� Any non-medical inpatient facility other than a therapeutic community

Therapeutic community unit �� Therapeutic communities (usually run by an NGO or religious organisation)

Other inpatient unit (specify) �� Any other inpatient facility

Specialised social reintegration /aftercare unit �� Outpatient or inpatient facilities for social reintegration and support after treatment

Other (specify) �� Any other facility not belonging to the categories above

the respondent was invited to continue with the survey. If

the respondent represented more than one unit providing

services to drug users, they were asked to complete the

questionnaire for each unit separately (Table 2).

In Bosnia and Herzegovina, data were collected in two

separate surveys, one for the Federation of Bosnia and

Herzegovina (FBiH) and one for the Republic of Srpska (RS).

The results of both are reported for Bosnia and Herzegovina

as a whole in this report.


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AlbaniaKEY DATA

Total population: in 2017, Albania had 2.9 million

inhabitants.

High-risk drug use: in 2014/15, estimates of the

number of high-risk drug users (primary opioid users)

in Albania ranged from 3 469 to 8 737. It is estimated

that 6 out of 10 high-risk drug users use drugs by

injection, with a large proportion of them injecting

daily (EMCDDA, 2017c).

Treatment population: approximately 1 130

individuals received drug treatment in Albania in

2015 (EMCDDA, 2017c).

l Overview of the treatment system in Albania

Treatment availability remains limited in Albania, and the

main focus is on OST. The public sector and NGOs are the

main stakeholders involved in drug treatment and harm

reduction service provision. There is only one public centre

that treats high-risk drug users, the Addictology and Clinical

Toxicology Service of Tirana University Hospital Centre

‘Mother Theresa’ (TUHC), formerly known as the Clinical

Toxicology Service. The TUHC, which has 20 beds, covers

the whole country, deals mainly with detoxification and

overdose treatment, and serves as both an inpatient and

outpatient unit. Other psychiatric services will not provide

treatment to high-risk drug users, unless they present with

psychiatric comorbidities. A second specialised inpatient

centre is operated by the NGO Emanuel, a therapeutic

community with around 20 beds.

Methadone maintenance treatment was first made

available in 2005 by the NGO Aksion Plus, funded by the

Soros Foundation. About 915 clients received free-of-

charge methadone treatment between 2005 and 2015

(an average of 90 clients per year). This included people

in custodial settings, as Aksion Plus offers methadone

maintenance treatment to prisoners who need it. Today,

Aksion Plus operates six units in Tirana and five other

districts. Currently, methadone is the only OST medication

available in Albania.

Data reported to the EMCDDA indicate that, of

approximately 1 130 drug treatment clients in Albania in

2015, three-quarters were treated in outpatient settings

(Figure 1). It should be noted that there is no common drug

treatment data collection system in Albania; treatment

facilities report their clients separately, possibly resulting in

double-counting of some clients.

The data available from the TUHC indicate that the

numbers of people entering drug treatment in the facility

annually have fallen since 2008, when 856 clients

entered treatment. The TUHC reports that 473 clients

entered drug treatment in 2015. The number of clients

who were entering treatment for the first time also varied

considerably between 2008 and 2015, with a low of 41

reported in 2008 and a high of 218 reported in 2009. In

2015, 150 new clients entered treatment.

Regarding the type of drug used by clients entering

treatment, a decline in the proportion of treatment

demands relating to opioid use was recorded between

2006 and 2012 (from 71 % to 29 %). However, this changed

in 2013, when the proportion of opioid-related treatment

demands increased, and by 2015 around 40 % of clients

were entering treatment primarily because of opioid use.

Demand for treatment related to cocaine use has increased

in recent years too. In 2015, cocaine was the second most

prevalent primary substance, accounting for one-third of

all treatment entries. The proportion of clients seeking

treatment for cannabis use has also gradually increased

since 2006, with approximately one-quarter of treatment

entries linked to cannabis use in 2015. The available data

also indicate a steady increase in polydrug use among

treatment clients.

l Findings from the 2017 treatment facility survey using the EFSQ in Albania

l SamplingAll district, regional and tertiary general hospitals, as

well as all major private hospitals in Tirana and all NGOs

working in the drugs field in Albania, were contacted. In

total, the invitation to participate was sent to 24 general

district hospitals, 11 general regional hospitals, one

tertiary hospital, two major private hospitals in Tirana


11

FIGURE 1

Total number of clients receiving treatment and units providing treatment by outpatient and inpatient unit type in Albania in 2015

Clients

Hospital-based residential drug treatment(416)

Low-threshold(565)

Specialised drug treatment centres(907)

Clients Units

Low-threshold(1)



Other inpatient(2)

Prisons(5)

Inpatient Outpatient

NB: ‘Other inpatient’ units are one acute drug intoxication treatment unit and one dual diagnosis inpatient treatment unit. No data are available on the total number of clients for prisons and ‘other inpatient’ units.

and three NGOs offering various services to people with

substance-related addictions, including alcohol. Preliminary

information indicated that primary healthcare centres and

polyclinics in Albania do not provide services to individuals

with substance-related problems, so these were not

included in the sampling frame.

The inclusion criterion for the survey was a positive

response to the question ‘Do you provide addiction

treatment, counselling or other services to clients/patients

with addiction problems (at least one person in previous 12

months with problems with use of tobacco and/or alcohol

and/or illicit drugs and/or gambling)?’ A translated version

of the EFSQ was sent in hard copy or by email to all 41

institutions in the sampling frame. One private hospital,

and all the district hospitals (24) and regional hospitals

(11) responded ‘no’ to the screening question and were

therefore excluded from the survey. The other private

hospital failed to provide the data required and was also

excluded. The final sample of facilities therefore comprised

the only tertiary hospital in the capital, Tirana, and three

NGOs working with people with addictions. The tertiary

hospital in Tirana had three units suitable to complete the

questionnaire, but one unit did not provide data. One NGO

had only one unit and another had six units. The third NGO

had two units: one was still operating, but the other had

ceased providing addiction services and answered ‘no’

to the screening question. In total, 10 units from 4 parent

organisations completed the EFSQ in Albania.

There were no particular legal or ethical issues involved.

The survey was carried out with the approval of the Ministry

of Health and all the institutions consented to participate

in the survey. Client data were anonymous and provided in

aggregated form.


12

In summary, the Albanian translated version of the EFSQ

was filled out by seven low-threshold units (six of them

providing OST), two hospital-based residential treatment

units and one specialised social reintegration/aftercare

unit. Between January and December 2016, these units

provided treatment to 2 585 clients, of whom 1 970 were

treated for a substance use-related problem.

l Results

Type of facilities, geographical distribution and fundingThe findings from this survey show that treatment services

are concentrated primarily in Tirana, the capital of Albania

(Table 3). In six prefectures of Albania (representing

approximately 30 % of the country’s total population),

public institutions or NGOs offering treatment services are

not available.

Overall, 8 of the 10 units offering services to individuals

with substance-related problems can be categorised as

NGOs, whereas the two remaining hospital-based inpatient

units were public institutions funded by the government.

The majority (80 %) of entities offering services to

individuals with substance-related problems reported that

they were funded either entirely (20 %) or partly (60 %)

from the state budget. Six units were financed jointly by

the state and the Global Fund, and two others had other

sources of funding. Low-threshold units reported serious

financial difficulties in the context of uncertain future

funding from the Global Fund in Albania and economic

constraints affecting other donor organisations.

Target population and client characteristicsThe 10 surveyed units provided treatment to 2 585 clients

in 2016. Two-thirds of these were served by hospital-based

residential units, 30 % were served by low-threshold units

and approximately 8 % were served by the specialised

social reintegration unit. Between 80 % and 90 % of clients

received treatment in Tirana.

The majority of clients (1 970, 76 %) were treated for

substance-related problems, including alcohol. Heroin

was the primary problem drug in 64 % of cases, followed

by cannabis (13 %), cocaine (11 %), and alcohol (9 %)

(Figure 2).

FIGURE 2

Proportion (%) of clients of surveyed facilities by primary substance in Albania in 2016 (EFSQ, 2017)

9 %

64 %

1 %

13 %

11 %1 % 1 %

Alcohol

Heroin

Other opioids

Cannabis

Cocaine

Non-cocaine stimulants

Hypnotics and sedatives

TABLE 3

Number of units by region and unit type in Albania in the 2017 EFSQ facility survey

Region(level 2)

Region (level 3)

Low-threshold

Outpatient specialised

Outpatient non-specialised

Hospital-based inpatient

Other inpatient

Specialised reintegration/aftercare

Total

Northern region

Diber 0 0 0 0 0 0 0

Durres 1 0 0 0 0 0 1

Kukes 0 0 0 0 0 0 0

Lezhe 0 0 0 0 0 0 0

Shkoder 1 0 0 0 0 0 1

Central region

Tirana 2 0 0 2 0 1 5

Elbasan 1 0 0 0 0 0 1

Southern region

Berat 0 0 0 0 0 0 0

Fier 0 0 0 0 0 0 0

Gjirokaster 0 0 0 0 0 0 0

Korce 1 0 0 0 0 0 1

Vlore 1 0 0 0 0 0 1

Total 7 0 0 2 0 1 10


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StaffingThere was a full-time equivalent (FTE) of 72.5 staff

employed across all 10 surveyed units. A breakdown

by profession types reveals that the main professions

represented in the survey are addiction or psychiatric

nurses (14.5 FTE), medical doctors specialised in addiction

medicine or addiction psychiatry (12 FTE), general nurses

(11 FTE) and psychologists (9 FTE).

The staffing of the units tends to reflect their nature

and operating field. Low-threshold units employ mostly

psychologists and social workers, while hospital-based

units employ mostly doctors specialised in addiction

treatment and addiction psychiatry, and both specialist

addiction and general nurses.

Provision of services and quality assuranceIn response to questions about the range of services

provided, all surveyed facilities in Albania reported that

they ‘frequently’ or ‘always’ provided counselling and

psychotherapy interventions and/or services. In addition,

all units indicated that they ‘frequently’ or ‘always’ provided

case-management services, and a large majority (between

80 % and 90 %) reported that they ‘frequently’ or ‘always’

provided brief psychosocial interventions, individual, group

and family counselling, and internet-based treatment.

OST was available in six out of the twelve level 3 regions in

the country and was provided by low-threshold units that

also dispensed the medication. In total, 719 clients had

received OST in the previous year, with the unit in Tirana

serving almost half of OST clients (345, 48 %). Eight out of

ten units included in the survey offered pharmacologically

assisted management of withdrawal, that is, detoxification

(all six low-threshold units and both of the hospital-based

residential treatment units).

All the low-threshold units and the specialised social

reintegration unit provided services to prison inmates

with substance-use problems. During 2016, a total of 900

prisoners received such services, with an overwhelming

proportion being offered to inmates in Tirana’s prisons.

However, nearly 90 % those receiving services did so from

one unit alone: the specialised social reintegration unit.

In addition, 80 % of all provider units in Albania reported

that they ‘frequently’ or ‘always’ offered services to children

and adolescents, clients with mental health and substance

disorders, sex workers, and ethnic and minority groups.

However, a lack of services for women and homeless drug

users was reported in the survey.

With regard to infectious disease testing and other related

services, only one unit reported that they ‘always’ or

‘frequently’ offered on-site HIV, hepatitis C virus (HCV)

and hepatitis B virus (HBV) diagnostic testing; and other

services related to infectious disease care were offered

even less frequently. On-site HBV vaccination, on-site HCV

infection treatment and on-site antiretroviral treatment

for HIV/AIDS were, in general, either rarely offered or not

offered, despite the perceived need for these services. The

survey indicated that these services were never offered in

hospital settings because there was not a perceived need

for them.

Various harm reduction services were offered by the

units included in the survey. The harm reduction service

most often reported (by 80 % of all units) as provided

‘frequently’ or ‘always’ was the distribution of information

material on safer injecting and drug overdose prevention.

This was followed by street outreach work, the distribution

of syringes and other drug-injecting equipment, and the

distribution of condoms (offered by 70 % of all units).

The distribution of information material targeted at

recreational drug users and partygoers was reported as

being ‘frequently’ or ‘always’ provided by only two units,

with seven others reporting that they either ‘rarely’ or

‘sometimes’ provided these services, and one unit reporting

that this service was not needed. Social reintegration

services, such as employment support or vocational

training, were offered by fewer units on a regular basis. Six

units reported offering these services ‘frequently’, but none

as a standard service (i.e. ‘always’). Six units sometimes

provided housing support, while the remaining four did so

‘rarely’ or ‘never’.

As social reintegration services for drug users in treatment

are more commonly taken care of by external health

and social institutions, most units had established

collaborations with at least one other health or social

institution. All units, except for one hospital-based unit,

collaborated with other health institutions (90 % of

units). Similarly, except for one low-threshold unit, all

units collaborated with social services, and all but one

hospital-based residential unit collaborated with other

specialised drug and alcohol treatment services. Eight of

the ten units (all except for one hospital-based unit and one

low-threshold unit) collaborated with prisons and probation

services, and the same proportion collaborated with

unemployment services.

All units reported having state-recognised accreditation,

but only one could provide proof or suggest a basis for

such recognition. Almost all units had internal and external

quality assurance mechanisms in place, although the

extent to which they were applied was unclear.


14

l Conclusions and implications

The findings from the 2017 EFSQ survey in Albania indicate

that access to treatment is constrained by the lack of

geographical coverage of the treatment services available

in the country. The estimated number of high-risk drug

users in Albania, compared with the number of those

currently receiving treatment, suggests that approximately

75 % of high-risk drug users are not reached by treatment

services. In addition, the survey findings indicate that some

key groups are currently inadequately served, including

homeless people and women. Harm reduction services

and counselling or psychotherapy interventions seem to be

widely available from existing service providers, but testing

for infectious diseases is rarely available, as are social

reintegration services.

The geographical disparity in the availability of treatment

and harm reduction services highlights the need to support

the implementation of new services outside the capital.

This is necessary to improve access to drug services in

other areas of Albania, to reduce the level of unmet needs

and to reduce the current burden on providers in the

capital city. In this regard, it may be useful to consider the

possibility of involving primary healthcare centres in the

provision of drug services. Another important implication

of these findings, and one requiring immediate attention,

concerns the underfunding of NGOs that have been largely

dependent on Global Fund financing in providing these

services.

Finally, internal and external quality assurance mechanisms

for service providers are crucial to improving the quality

of care, yet the findings of the survey suggest that these

may not be consistently applied. It is suggested that state

accreditation processes be improved in order to establish

and ensure compliance with quality standards for care

provision, staffing and infrastructure. In addition, with

regard to improving the quality of care in the Albanian

treatment system, further studies are needed to identify

barriers to accessing treatment. A better understanding of

why high-risk drug users are not accessing treatment, and

of client satisfaction with the current services, could be an

important part of the evaluation of the treatment system.


15

Bosnia and HerzegovinaKEY DATA

Total population: in 2015, Bosnia and Herzegovina

had 3.8 million inhabitants.

High-risk drug use: in 2009, the estimated number

of people who inject drugs was 889 (95 % CI:

703-1075) in Sarajevo, 534 (95 % CI: 354-717) in

Banja Luka and 852 (95 % CI: 809-895) in Zenica.

These results were extrapolated to entity and state

levels to give an estimated population of people who

inject drugs in the FBiH in 2009 of 4 900; for the

whole of Bosnia and Herzegovina, this would amount

to 7 500 people (EMCCDA, 2018b).

Treatment population: in 2015, 2 115 treatment

clients were registered in Bosnia and Herzegovina, of

whom 1 310 received OST (EMCCDA, 2018b).

l Overview of the treatment system in Bosnia and Herzegovina

Bosnia and Herzegovina has a state level government

and comprises two autonomous entities, the Republic of

Srpska (RS) and the Federation of Bosnia and Herzegovina

(FBiH), with a third region, the Brčko District, under local

government. Public health issues are the responsibility of

the two entities and of the District, and the provision of

drug-related treatment is under their oversight. In the RS,

the Ministry of Health and Social Welfare is the responsible

institution, while in the FBiH responsibility is shared

between the federal ministry and the cantons. At state

level, the Ministry of Civil Affairs is in charge of the overall

coordination of public health.

The health system in Bosnia and Herzegovina (in the two

entities and the Brčko District) is divided into primary,

secondary and tertiary levels. Treatment of drug users

(counselling, detoxification and OST) is available through

inpatient and outpatient facilities, but most provision is

through outpatient facilities (Figure 3). The primary level

includes family medicine, some specialised services,

and community mental health centres where counselling

services, early detection, and treatment of mental disorders

are provided. The secondary level includes outpatient

and inpatient programmes for counselling, detoxification

and OST in specialised centres, in psychiatric clinics or

hospitals, or in psychiatric departments in general hospitals

in smaller towns and in the Brčko District. There are five

outpatient specialised drug treatment centres, which

provide OST in Mostar, Tuzla and Zenica, Banja Luka, and

Sarajevo, the largest urban areas in the country. OST is

not available in the Brčko District or in prisons in the RS.

Between 2006 and 2016, OST was funded by the Global

Fund. To prepare for the withdrawal of the Global Fund

from Bosnia and Herzegovina, a transition plan was drawn

up by the national authorities. The tertiary level covers

rehabilitation and social reintegration programmes, mainly

implemented in therapeutic communities (mostly set up by

NGOs).

Access to treatment is available and free of charge for

those with health insurance. People who do not have health

insurance have to pay for treatment in accordance with the

price list for medical services.

Harm reduction services (e.g. the distribution of syringes

and other drug-injecting equipment, overdose prevention

leaflets, etc.) are offered through networks of outreach

workers and 10 drop-in centres. Annually, around 3 100

injecting drug users receive support through these

networks.

According to data from the Institutes for Public Health

of the FBiH and the RS, 2 115 treatment clients were

registered in Bosnia and Herzegovina in 2015, and there

has been a slight increase in the number of clients treated

in recent years. The available data indicate that the majority

of treated clients use heroin or other opioids. More than

60 % of clients treated in the country received OST. In 2015,

a total of 1 310 people were receiving OST, with methadone

being the most prescribed maintenance treatment. The

available data indicate an overall increase in the number of

OST clients since 2011.

l Findings from the 2017 treatment facility survey using the EFSQ in Bosnia and Herzegovina

l SamplingIn the RS (and the Brčko District), the translated version of

the EFSQ was first piloted in three mental health centres

to test for inconsistencies. The Ministry of Health and


16

Social Welfare of the RS provided the list of institutions

to be surveyed. The inclusion criterion for participation

in the survey was the generic criterion used across all

countries: a positive response to the question ‘Do you

provide addiction treatment, counselling or other services

to clients/patients with addiction problems (at least one

person in previous 12 months with problems with use

of tobacco and/or alcohol and/or illicit drugs and/or

gambling)?’ The translated version of the EFSQ was sent

to 41 facilities by email, 32 of which met the inclusion

criterion and filled out the EFSQ.

For the FBiH, the sampling procedure was similar. The

inclusion criterion was all facilities in the Federation of

Bosnia and Herzegovina that had treated at least one

client/patient with an addiction-related problem in the

period between January and December 2016. The list

of facilities selected for the study was completed at the

beginning of March 2017. The following sources were

used to create the list of institutions to be invited to

take part in the survey: the national report on the drug

situation in Bosnia and Herzegovina from 2014; data

from the treatment system mapping exercise carried out

during the annual TDI expert meeting in Lisbon in 2016

(see Chapter 2); data from the Federal Public Health

Institute; and data from the Department of Health in the

Ministry of Civil Affairs of Bosnia and Herzegovina. Some

facilities were removed from the list because of a closure

or a shift in the services provided. Facilities known to have

opened recently were added to the list. The pilot study in

the FBiH was performed internally at the Public Institute

for Addiction Disorders of the Canton of Sarajevo, and

externally by one therapeutic community in the Canton of

Sarajevo. All the facilities were contacted initially by phone

and were subsequently sent an email with the translated

version of the EFSQ, as well as a letter from the Federal

FIGURE 3

Total number of clients receiving treatment and units providing treatment by outpatient and inpatient unit type in Bosnia and Herzegovina in 2015 or the most recent year

Clients Units

General healthcare and general mental healthcare(211)



Prisons(242)


Low-threshold(10)



Residential drug treatment (non-hospital-based)(422) Specialised drug

treatment centres(5)

Residential drug treatment (non-hospital-based)(10)

Prisons (2)

NB: no data are available on the total number of clients in low-threshold units.


17

Public Health Institute explaining the purpose and process

of the survey. The translated version of the EFSQ was sent

to 30 facilities by email, with 23 of them taking part in the

survey.

There were no particular legal or ethical issues involved in

either the RS or the FBiH. The survey was carried out with

the approval of the health ministries and all the institutions

consented to participate in it. Client data were anonymous

and provided in aggregated form.

A total of 55 facilities took part in the survey using the

EFSQ in Bosnia and Herzegovina.

l Results

Type of facilities, geographical distribution and fundingThe Bosnian version of the EFSQ was filled out by 55

facilities, 38 of which were outpatient facilities and 17

of which were inpatient facilities. Of the former, non-

specialised outpatient units were predominant in the RS,

there being only one specialised outpatient treatment unit.

Conversely, in the FBiH, specialised outpatient treatment

units were more common than non-specialised outpatient

units. Hospital-based residential treatment units and

therapeutic communities were available in both the RS and

the FBiH. No low-threshold units took part in the survey

(Table 4).

In the FBiH, there are two specialised centres, in Sarajevo

and Zenica, as well as psychiatric wards for the treatment

of drug users in Mostar and Tuzla. Overall, the geographical

distribution of drug treatment services is concentrated

in the big cities and there is a lack of services in south-

western regions, as well as in the Goražde area. In the

RS, outpatient services are predominantly provided by

generic mental health centres, with an overall lack of

specialised outpatient institutions for the treatment of

substance-related problems. The eastern part of the

RS has no inpatient centres, and shows an uneven

territorial distribution of OST centres, with most of them

concentrated in the western part of the RS.

The main source of funding, as reported by most facilities in

Bosnia and Herzegovina, is from the government, through

the state budget, municipal budgets or health insurance

funds. Twenty-nine institutions indicated that they were

funded by the state budget (one unit did not respond to

this question), and 21 institutions (mental health centres)

indicated that they were funded by municipal budgets. Six

units providing OST were receiving funding from the Global

Fund, while 12 units reported additional sources of funding

(from therapeutic communities and associations). The NGO

Viktorija and the therapeutic community Izvor are funded

by grants and projects.

Target population and client characteristicsFor the whole of Bosnia and Herzegovina, results from

the facility survey using the EFSQ show that the majority

of clients received treatment through outpatient services.

A total of 2 190 individuals received treatment through

outpatient specialised services, and 1 726 clients received

treatment in non-specialised general mental healthcare

centres during the 12 months prior to the facility survey

(Figure 4). In addition, 1 711 clients received treatment

in hospital-based inpatient units, 444 clients received

treatment in aftercare/social reintegration units, and 131

clients received treatment in therapeutic communities.

TABLE 4

Number of units by region and unit type in Bosnia and Herzegovina in the 2017 EFSQ facility survey

Region Low-threshold




Therapeutic community unit

Other inpatient


Total

Republic of Srpska

0 1 21 6 1 0 1 30

Brčko District

0 0 1 1 0 0 0 2

Federation of Bosnia and Herzegovina

0 10 5 3 3 0 2 23

Total 0 11 27 10 4 0 3 55


18

FIGURE 4

Total number of clients by unit type in Bosnia and Herzegovina in 2016 (EFSQ, 2017)

0

131

444

1711

1726

2190

Low-threshold

Other inpatient

Aftercare

Medical inpatient



Republic of Srpska Federation of BiH

Overall, in Bosnia and Herzegovina, 45 % of clients received

treatment for alcohol-related problems and 41 % for illicit

drug-related problems. Smaller proportions received

treatment for the misuse of pharmaceuticals (4.6 %) and

behavioural addictions related to gambling (2 %) (Figure 5).

One difference stands out between the two entities: in

the RS there were far more clients with alcohol-related

problems (68 %) than with illicit drug-related problems

(18 %), while in the FBiH the majority of clients reported

illicit drug-related problems (73 %), followed by alcohol-

related problems (13 %). This difference may be explained

by the nature of the facilities providing services in each

entity: non-specialised outpatient facilities in the RS

address broader substance-related problems, including

alcohol, while, in the FBiH, specialised drug treatment

centres focus primarily on illicit drugs.

Among those receiving treatment because of illicit drug

problems in Bosnia and Herzegovina, heroin was the

primary drug (31 %), followed by cannabis (7 %), other

opioids (5.7 %) and stimulants (2.4 %) (Figure 6).

StaffingIn the whole of Bosnia and Herzegovina, there was a full-

time equivalent (FTE) of 965.1 staff employed across all

surveyed units. A breakdown by profession types (Figure 7)

FIGURE 5

Proportion (%) of clients by primary problem substance or behaviour among surveyed facilities in Bosnia and Herzegovina in 2016 (EFSQ, 2017)

68 %

18 %

2 %

4 %

9 %13 %

73 %

2 % 5 % <1 %

45 %

41 %

2 %5 %

5 %

Alcohol

Illicit drugs

Gambling

Misuse of pharmaceuticals/medicines

Other disorders/health problems

Republic of Srpska Federation of BiH Total BiH

FIGURE 6

Proportion (%) of clients by primary substance among surveyed facilities in Bosnia and Herzegovina in 2016 (EFSQ, 2017)

47 %

31 %

6 %

8 %

1 % 2 %3 % 3 %

Alcohol

Heroin

Other opioids

Cannabis

Cocaine


Volatile inhalants


10 %

12 %

7 %

2 %2 %

6 % 1 %

60 %

72 %

10 %

2 %

8 %

3 %< 1%

4 %< 1%

Republic of Srpska Federation of BiH Total BiH


19

reveals that the main professions represented in the

survey are general nurses (301.5 FTE), administrative

staff (195 FTE), psychologists (98.2 FTE) and general

psychiatrists (84 FTE). However, large differences

exist between the two entities. In the RS, the medical

professionals (medical doctors and nurses) employed

in treatment facilities are not specialised in addiction,

although it can be assumed that experience is gained

from working in the field for numerous years. The opposite

is observed in the FBiH, where medical professionals

specialised in addiction are employed across the surveyed

facilities. Again, differences between the two entities

may be explained by the lack of specialised services in

addiction and substance-related problems in the RS, which

may result in little uptake of addiction studies by medical

professionals.

Provision of services and quality assuranceResults on the range of services provided across the

surveyed facilities in Bosnia and Herzegovina show that

their primary focus is on psychosocial and therapeutic

care of individuals with substance-related problems,

and OST provision. Between 50 % and 70 % of the

facilities reported that they ‘frequently’ or ‘always’ provide

individual counselling or brief interventions and, to a lesser

extent, family counselling (30 %). Psychotherapeutic

and socio-therapeutic activities are mostly carried out in

specialised institutions for treating addiction, while mental

health centres provide primarily brief interventions and

case management. On the other hand, harm reduction

interventions (e.g. syringe exchange, materials for overdose

prevention), testing for and treatment of infectious

diseases, and social reintegration services are for the most

part either rarely provided or not available. The facility

that reported the availability of the most harm reduction

activities was the NGO Viktorija.

Less than 5 % of facilities reported that they frequently

provide on-site HCV testing and approximately 6 %

reported frequent on-site HBV testing. Frequent testing for

an HIV infection was reported by approximately 2 %. The

only institution offering HCV treatment to drug users was

the University Clinical Centre of the Republic of Srpska. In

the FBiH, none of the units answered ‘frequently’ or ‘always’

in regard to testing for or treatment of infectious diseases.

This is because most units refer patients to other clinics or

departments of primary healthcare centres for testing for

infectious diseases.

OST provision in the RS takes place in three mental health

centres (Doboj, Trebinje and Sokolac) and in one specialised

psychiatric outpatient service at General Hospital Bijeljina.

The OST programme in Banja Luka works as a separate

unit. There is currently only one centre for detoxification

(the Department of Addiction at the Psychiatric Clinic,

Banja Luka). In the FBiH, the Sarajevo Canton has adopted

a centralised approach to OST, whereby it is provided only

at the Institute for Alcoholism and Substance Abuse of the

Canton of Sarajevo. In contrast, a decentralised approach is

taken in Zenica, where the Institute for Addictions of Zenica

Canton provides support for OST dispensing units located

in outpatient mental health centres in smaller cities (Breza,

Maglaj, Doboj Jug, Kakanj, Tešanj and Visoko). A similar

principle is applied in Una-Sana Canton, where the OST

units operate as part of outpatient mental health centres or

primary healthcare centres. In the FBiH, pharmacologically

assisted detoxification is available in Sarajevo, Zenica, Tuzla

and Mostar.

The results from the facility survey in Bosnia and

Herzegovina revealed that 1 675 individuals were

prescribed OST in 2016, through 22 units. Ten specialised

outpatient treatment centres prescribed OST to 1 163

clients; nine mental healthcare centres prescribed it to

356 clients; and three hospital-based residential treatment

units to 156 clients. All units provide prescriptions for the

medications and all but one also dispense the medication

to the patient.

Regarding quality assurance mechanisms, 14 units

reported that they possessed a certified state accreditation,

FIGURE 7

Staffing (FTE) by professional category in Bosnia and Herzegovina in 2016 (EFSQ, 2017)

302

195

98

84

78

58

48

41

37

21

4Pharmacists

Medical doctors specialised in addiction medicine or addiction

psychiatry

Medical doctors not specialised in addiction medicine or addiction

psychiatry

Other sta� involvedin service provision

Other professional therapists

Social workers

Addiction/psychiatricnurses

General psychiatrists

Psychologists

Administrative personnel

General nurses

Republic of Srpska Federation of BiH


20

11 in the RS and three in the FBiH. In the RS, nine mental

health centres, one therapeutic community, and one

department of addiction at the Psychiatric Clinic held

certified state accreditation. In the FBiH, two mental health

centres operating within primary healthcare centres (Dom

Zdravlja) and one NGO counselling centre stated that they

had state agency accreditation (Accreditation Agency for

Healthcare Standards). The majority of surveyed facilities

in Bosnia and Herzegovina reported having internal quality

assurance mechanisms in place. Over 70 % of facilities

reported possessing manuals of procedures, carrying out

regular team meetings, providing continuous learning and

knowledge transfer activities for staff, and collecting and

documenting client satisfaction feedback.


These results are based on the 55 units that responded to

the 2017 EFSQ survey in Bosnia and Herzegovina.

Drug treatment facilities are unevenly distributed

geographically, with the majority of facilities located in

the biggest cities (Banja Luka and Sarajevo), leaving the

eastern part of the Republic of Srpska and two cantons

of the FBiH (Canton 10 and West Herzegovina) without

access to local treatment. Currently, OST is provided in

a few prisons in the FBiH. While the current provision in

these prisons should be commended, the units involved

(as well as other relevant units and institutions) could be

encouraged to expand the provision of OST and harm

reduction interventions to other prisons in the country.

Clients in treatment for alcohol-related problems are

more prevalent in the RS than in the FBiH. In the FBiH,

more clients are in treatment for drug use, although

the number of patients treated for drug use in the RS is

increasing. Among patients treated for drug use, heroin

is the main problem substance, followed by cannabis

and other opioids. In the FBiH, the majority of treatment

centres provide OST, while only a limited number of beds

or outpatient treatment programmes for alcohol addiction

were observed. This may have led to the underestimation

of the number of people with alcohol problems in the

treatment population, which could explain the difference

between the two entities.

Several staffing issues (shortages, burnout, lack of

specialisation) and stigma towards drug users and

professionals working with them were reported. Efforts at

governmental level could be considered to raise awareness

about addiction among the general population and to offer

more training to staff working in specialised addiction

services or treatment centres.

Since September 2016, the Global Fund has stopped

its financing activities in Bosnia and Herzegovina. The

funding for various programmes implemented over the

last 10 years is now to be ensured by the government, as

stipulated in the Transition Plan for the Continuation of HIV

and Aids Prevention, Treatment and Care in Bosnia and

Herzegovina 2015-2017. Finally, as public health matters

are under the responsibility of various institutions working

as part of a complex structure, a strong coordination

mechanism is required, with the support and dedication of

all stakeholders.


21

KosovoKEY DATA

Total population: in 2017, Kosovo had 1.9 million

inhabitants.

High-risk drug use: no estimates of the number of

high-risk drug users in Kosovo exist. The most

frequently cited estimate of the drug-using

population is between 10 000 and 15 000

individuals, and of these between 4 000 and 5 000

are thought to be heroin users (EMCDDA, 2014).

Treatment population: n.a.

l Overview of the treatment system in Kosovo

In June 2012, the government approved Kosovo’s anti-drug

strategy and action plan for 2012-17, with a particular

focus on increased cooperation between responsible

institutions. The strategy is based on five pillars: demand

reduction and harm reduction; supply reduction;

cooperation and coordination; support mechanisms; and

supervision and monitoring. General goals and specific

objectives have been incorporated into these pillars.

Outpatient and inpatient treatment options in Kosovo remain

limited, although they are slowly expanding (Figure 8). Two

agencies, the Psychiatric Clinic of the University Clinical

Centre of Kosovo in Pristina and the NGO Labyrinth, provide

most of the drug treatment in the form of detoxification

services, psychosocial treatment and OST with methadone.

Outpatient psychosocial drug treatment is primarily provided

by Labyrinth, which has units in Prizren, Gjilan and Pristina.

The implementation of methadone maintenance treatment

was initiated in April 2012, as part of a Global Fund-

supported project at Labyrinth, and it was subsequently

introduced in the Psychiatric Clinic of the University Clinical

Centre of Kosovo and in regional hospitals in Gjilan and

Gjakova. Two methadone programmes are operating

in custodial settings (prisons) in Kosovo. Methadone

maintenance treatment is still primarily financed by the

Global Fund, and is being expanded in terms of both

number of clients and geographical coverage. Primary

healthcare providers and public social services are not

involved in the treatment of high-risk drug users. This is

mainly because of a lack of appropriate training and a lack

of understanding of these providers’ potential role in the

field of drug treatment.

Harm reduction programmes were first provided in 2005

by Labyrinth in Pristina. These programmes are now also

available in Prizren and Gjilan, with support from the Global

Fund.

There is no data-collection system that covers drug

treatment for the entire territory of Kosovo, and the centres

involved in treatment provision keep records of their clients

separately. The psychiatric clinic provides outpatient and

inpatient treatment and represents the main source of

information on treatment demand. Data provided by this

unit since 2005 indicate a gradual increase in demand for

FIGURE 8

Total number of units by outpatient and inpatient unit type providing substance-related treatment in Kosovo in 2015

Units




Low-threshold(10)



Prisons (2)

�erapeutic communities(1)

NB: data on the total number of clients by unit type are not available, with the exception of the hospital-based residential treatment unit, which had 60 clients in 2015.


22

treatment up to 2009. There were 147 treatment requests in

2005 and 198 in 2009. However, the latest data reported to

the EMCDDA indicate that there were 159 requests in 2011.

l Findings from the 2017 treatment facility survey using the EFSQ in Kosovo

l SamplingA mapping of institutions to be surveyed was carried out in

collaboration with Labyrinth and the Ministry of the Interior,

which provided a list of facilities that report twice a year as

part of monitoring under the national strategy. The Institute

of Public Health also provided a list of public institutions

that might provide services to drug users. As a result,

the following institutions received an invitation letter and

a translated version of the EFSQ: the Psychiatric Clinic of

the University Clinical Centre of Kosovo, regional hospitals

in the municipalities of Gjilan and Gjakova, Labyrinth (one

specialised outpatient centre in Pristina and two low-threshold

centres in Gjilan and Prizren), the therapeutic community

Streha, in Gjilan, and the Emergency Clinic of the University

Clinical Centre of Kosovo. All the facilities but one met the

inclusion criterion and participated in the facility survey

(Table 5). The emergency clinic was excluded because of

a negative response to the inclusion criterion question.

Although it was requested that each unit fill out the EFSQ

separately, data collection for all the units operated by

Labyrinth were processed as one. As a consequence, the data

on Labyrinth in this report are aggregate data for all their units.

Kosovo used the translated Albanian version of the EFSQ

and sent the survey to Labyrinth for pre-testing and

language checking. There were no particular legal or ethical

issues involved.

l Results

Type of facilities, geographical distribution and funding

Pristina regionTwo units that operate in the capital city, Pristina, took part

in the survey. Labyrinth operates a specialised outpatient

treatment unit, which also provides OST. The second unit

is a hospital-based residential treatment unit, operated

with government funding by the Psychiatric clinic of the

University Clinical Centre of Kosovo.

Gjilan and Prizren regionsIn the Gjilan and Prizren regions, four units participated in

the survey. A government-funded regional hospital-based

inpatient unit, which provides OST, and a low-threshold

unit, run by Labyrinth, operate in the Gjilan region.

Additionally, a privately funded inpatient therapeutic

community called Streha also operates in that region.

A low-threshold unit operates in the Prizren region and is an

NGO (a branch of Labyrinth).

Peja and Mitrovica regionsThe Peja region has one government-funded regional hospital,

which operates an OST programme, whereas the Mitrovica

region, based on data from this survey, has no services for

TABLE 5

Number of units by region and unit type in Kosovo in the 2017 EFSQ facility survey





Other inpatient


Total

Pristina region 0 1 0 1 0 0 2

Gjilan region 1* 0 0 1 1 0 2 (3*)

Peja region (Municipality of Gjakova)

0 0 0 1 0 0 1

Prizren region 1* 0 0 0 0 0 0 (1*)

Mitrovica region 0 0 0 0 0 0 0

Total 2* 1 0 3 1 0 5 (7*)

NB: data from the two low-threshold units (marked with an asterisk) in Gjilan and Prizren regions were reported in the responses submitted by the outpatient specialised treatment unit in Pristina. All three units are operated by the same NGO.


23

drug users. Drug users from Mitrovica seeking support are

reported to travel to Pristina to obtain drug services.

The overall geographical distribution of facilities that

offer OST is relatively limited. Since 2012, OST has been

provided by the Psychiatric Clinic and Labyrinth in Pristina,

and by two regional hospitals in Gjilan and Peja. Two

big regions, Mitrovica in the northern part of Kosovo and

the Prizren region, in the southern part, do not have any

services offering OST.

All OST programmes are operating with the financial

support of the Global Fund and, for the time being, there

is no contingency strategy in case funding is discontinued.

In the event of funding disruption, the only option currently

available to people undergoing OST is to purchase the

methadone themselves in pharmacies with a prescription

from a psychiatrist working in a general healthcare unit.

Target population and client characteristicsThe findings from the survey revealed that 746 clients

were treated for licit and illicit substance-related problems

(substance and behavioural addictions) across all treatment

units during the 12-month period covered by the survey.

The largest proportion of clients was reported by outpatient

services (specialised and non-specialised). It should be

noted that the number of clients receiving services from

the two low-threshold units in the country are included in

specialised outpatient treatment since, as indicated above,

Labyrinth provided aggregated data for its services. There

were 243 people enrolled in OST programmes during that

period, one-third of the 746 clients reported in this survey.

The findings show that the facilities included in the

survey provided services primarily to heroin users (57 %

of all clients), cannabis users (23 %) and, to a lesser

extent, clients with problems associated with the use of

opioids other than heroin (Figure 9). The low proportion of

individuals with alcohol problems appears to indicate that

services addressing alcohol-related dependence operate

separately from drug-related services in Kosovo.

StaffingStaffing remains a challenge for facilities that provide

services for addiction-related problems. The survey

results indicated that there were 62 paid employees and

one unpaid volunteer, representing a total FTE of 41.

Medical doctors specialised in psychiatry (10), addiction/

psychiatric nurses (8) and general nurses (14) represented

approximately half of the total number of paid staff in all

facilities that participated in the survey. The other half

included psychologists, social workers, pharmacists,

medical doctors not specialised in psychiatry, other health

workers without a degree and administrative staff.

Provision of services and quality assuranceBased on data from the respondents, methadone

maintenance treatment is provided in four units: one

specialised outpatient treatment unit, one hospital-

based residential treatment unit and two general mental

healthcare units. The results from the facility survey

showed that 243 clients were reported to have received

OST during the reference period (2016) and seven others

were on the waiting list for OST. Pharmacologically assisted

management of withdrawal (detoxification) programmes

are also provided by all of these units and by the

therapeutic community Streha.

Of all the surveyed units in Kosovo, only one, a general

mental healthcare unit in Gjakova, responded that

it provided services to prisoners in 2016, namely to

four prisoners. It should be noted that two methadone

programmes operate in prisons in Kosovo, although the

units providing these programmes did not take part in the

national facility survey.

The availability and provision of harm reduction services,

such as street outreach work, distribution of syringes

and other drug-injecting equipment or distribution of

information material on safer injecting and drug overdose

prevention, is limited within the surveyed facilities. Only

20 % to 25 % of surveyed facilities reported that they

‘frequently’ provide these services, while in most facilities

these services were not provided and were reported as not

needed. These results may reflect the lack of low-threshold

services in the country and the treatment-oriented nature

of the facilities taking part in the survey.

FIGURE 9

Proportion (%) of clients of surveyed facilities by primary substance in Kosovo in 2016 (EFSQ, 2017)

3 %

57 %9 %

23 %

3 %4 % 1 %

Alcohol

Heroin

Other opioids

Cannabis

Cocaine


Other


24

These results are confirmed by the high availability

of psychosocial intervention across the surveyed

facilities. Individual and group counselling, as well as

case management and brief interventions, are the most

frequently provided psychosocial interventions (between

60 % and 75 % of units provide these interventions

‘frequently’ or ‘always’).

Social reintegration services are rarely offered, with most

facilities reporting that they ‘never’ or ‘rarely’ provide such

services. This may be due to either an overall lack of social

reintegration services or the fact that such services are provided

by separate social institutions. The latter situation requires

efficient partnerships between treatment providers and other

service providers to ensure continuity of care and effective

housing and employment opportunities. However, while all

the surveyed facilities reported established partnerships with

health institutions (e.g. hospitals, general practitioners), only

the outpatient specialised unit and one of the hospital-based

inpatient units reported an established partnership with social

services or prison and probation services.

Finally, despite injecting drug users being a high-risk

group in regard to the transmission of infectious diseases

and the high prevalence of HCV infections among this

group in Kosovo (EMCDDA, 2015), only 20 % of surveyed

facilities reported frequent or systematic on-site testing

for infectious diseases (Figure 10), while provision of

treatment or vaccination for these diseases occurs rarely.

FIGURE 10

Proportion (%) of surveyed facilities providing testing for or treatment of infectious diseases ‘frequently’ or ‘always’ in Kosovo in 2016 (EFSQ, 2017)

20 %

20 %

20 %

On-site HCV diagnostic testing

On-site HBVdiagnostic testing

On-site ART treatment for HIV/AIDS

On-site HIV diagnostic testing

On-site HBV vaccination

On-site HCVinfection treatment

0 %

0 %

0 %

‘Frequently’ or ‘always’


By providing a deeper insight into the reality of treatment

facilities in Kosovo, the EFSQ survey shows that a number

of core services are well established. However, they are

unevenly distributed, leaving significant areas of the

country without treatment coverage. The results also show

that the current range of available services remains limited.

For example, while harm reduction services are now

available in three municipalities (all through Labyrinth),

they are not provided by other drug treatment units

operating elsewhere in the country. Further expansion

of core services within a wider national context should,

therefore, be prioritised. Despite continued efforts, only

a small proportion of the estimated number of people who

inject drugs and use opiates such as heroin have access

to treatment services. Furthermore, methadone remains

the only opioid substitution medication available to people

with opiate-use problems. In this regard, enabling a wider

range of general healthcare providers to prescribe OST and

introducing a larger variety of OST medications, including

buprenorphine-based medications, should be considered.

The geographical disparity in the availability of treatment

and harm reduction services highlights the need to

increase the availability of such services outside the

capital. Each region and municipality should allocate some

funds to providing various types of services, so that people

who inject drugs have easier access to needle and syringe

exchange programmes, OST, and HIV, HCV and HBV testing.

Finally, the number of qualified service providers

throughout Kosovo, as revealed by this survey, remains

small by comparison with the number of people who use

or inject drugs. In this respect, funds could be allocated to

capacity building and training of existing staff, as well as

hiring more qualified professionals, to allow the expansion

of services throughout Kosovo.


25

SerbiaKEY DATA

Total population: as of 1 January 2017, Serbia has

7.05 million inhabitants.

High-risk drug use: for Serbia, data are available only

for the estimated number of people who inject drugs,

which was approximately 20 500 (95 % confidence

interval 16 300 to 27 700) in 2013 (EMCDDA,

2017d).

Treatment population: the latest available data

mention that, in 2015, 2 312 individuals received

OST in Serbia (EMCDDA, 2017d).

l Overview of the treatment system in Serbia

Drug treatment in Serbia falls under the responsibility

of the Ministry of Health. The Ministry has established

a coordinating and advisory body in the field of drugs:

the Republic Expert Commission for the Prevention and

Control of Drug Use.

The Law on Psychoactive Controlled Substances, the Law

on Health Protection, the Law on Protection of Persons

with Mental Disabilities, the Law on the Rights of Patients

and the Law on Drugs and Medical Devices regulate the

provision of drug treatment. Treatment-related objectives

of the Strategy for Drug Abuse Suppression 2014-21

emphasise diversification and the quality of drug treatment

by introducing new treatment approaches; promoting

treatments that contribute to the reduction of drug-related

infectious diseases and drug-induced deaths; expanding

access to treatment in prison; and promoting social

protection, rehabilitation and reintegration programmes for

drug users to minimise social exclusion and discrimination.

Drug treatment in Serbia includes medical detoxification,

medication-assisted treatment (with opioid agonists and

opioid antagonists), and psychosocial treatments, either

as short-term interventions (motivational interviewing,

individual psychosocial counselling, individual and group

psychotherapy) or long-term rehabilitation group and family

therapy. In general, drug treatment is financed through the

national Health Insurance Fund.

Drug treatment is provided by state healthcare facilities,

and some private health institutions also provide these

services. At primary healthcare level, treatment is provided

by health centres, and is mostly centred on counselling.

Clients are referred to secondary and tertiary healthcare

facilities for further treatment. At secondary level, drug

treatment is provided by psychiatrists in general hospitals,

while specialised drug treatment facilities (tertiary level)

are available in Belgrade, Novi Sad, Kragujevac and Niš.

These are reference centres for the implementation

and supervision of health protection and for developing

methodologies for drug prevention, treatment and

rehabilitation. Residential treatment is provided in six

therapeutic communities (one of them serving women)

by the Serbian Orthodox Church, which, in recent years,

has served around 200 clients per year. In 2014, the NGO

Rainbow provided care and housing to 72 drug users.

Methadone maintenance treatment was first

introduced into Serbia at the end of the 1970s, whereas

buprenorphine was registered for the treatment of opioid

dependence in 2010. Currently, OST is available in all types

of health facilities (26 units in 2015) and can be initiated

in an inpatient or outpatient healthcare facility; however,

the decision to initiate the treatment must be made by

a specialised treatment team.

In 2014, 16 of the 26 outpatient treatment units and all

three inpatient treatment units provided data on clients

entering treatment. A total of 494 clients entered treatment

in Serbia in 2014, most of them as outpatients. However,

more than half of first-time treatment clients received

treatment in inpatient settings (Figure 11).


26

The majority of the clients entered treatment as a result of

opioid use. The Serbian TDI currently covers mainly OST

services. In 2015, 2 312 persons received OST in Serbia,

1 460 of whom received methadone and 852 of whom

received buprenorphine. The available data indicate that

the number of OST clients has increased since 2011, when

1 430 OST clients received methadone and 79 received

buprenorphine.

l Findings from the 2017 treatment facility survey (WHO-UNODC Substance use disorder treatment facility survey)

l SamplingThe WHO-UNODC Substance use disorder treatment

facility survey questionnaire was used in Serbia with

the aim of collecting relevant information on available

resources for the treatment of drug use disorders in the

country.

The first version of the questionnaire was finalised in

June 2015. It was then translated into the local language

and submitted to both the Ministry of Health and the

Government Commission for the Control of Psychoactive

FIGURE 11

Total number of clients receiving treatment and units providing treatment by outpatient and inpatient unit type in Serbia in 2015

Clients Units


Low-threshold(4618)


Prisons (343)


Sp

ecia

lised

d

rug

trea

tmen

t c

entr

es (

49

4)


Other (201)

Residential (non-hospital-based) (7)


Residential (non-hosp.) (295) Prisons (1)


Low-threshold(8)

Other (2)

NB: data on the total number of clients from outpatient specialised treatment centres is from 18 units. Data on the total number of clients and units from hospital-based residential treatment and general healthcare and mental healthcare units does not include data from Metohija.


27

Controlled Substances for review and comments. The

comments related to the terminology that had been used in

the instrument, and they provided more information on the

cultural adaptation required, suggesting the use of terms

that were expected to be clearer for treatment facilities. As

agreed with the Ministry of Health, a pilot of an electronic

version of the instrument was then carried out online, using

a web-based survey platform hosted on a WHO server in

Geneva.

Subsequently, between 15 October and 1 December

2017, substance use disorder treatment facilities were

contacted by the Ministry of Health. Data were submitted

on a specially created web platform hosted on a local

server in Serbia. The facilities that did not respond initially

were reminded by phone. In total, data were collected from

39 out of the 53 contacted facilities, which corresponds

to a response rate of 74 %. Consequently, it is important

to note that the results cannot be generalised and are

not a sufficient basis for a full assessment of the overall

national coverage of substance use treatment in Serbia.

Of the 39 facilities, 20 provided data online, 15 filled in the

questionnaire in an electronic format, two sent scans of

the completed questionnaire and two replied by post. The

results show that not all facilities in Serbia were prepared

to participate in an online survey. The reasons for this

may include lack of technical equipment, and perhaps

insufficient technological literacy.

The data were processed by the UNODC in Belgrade

and submitted for further analysis to a national working

group, which comprised representatives of the regional

clinical centres (departments for substance use

disorders) in Belgrade, Novi Sad, Niš and Kragujevac, and

representatives of the Ministry of Health.

Ethical concernsThe survey was implemented and coordinated with the

Ministry of Health. It was agreed that contact data on facilities

providing information would not be published, and that the

information on the scope of the services provided to clients in

relation to primary substances (Section D), would be available

only to the administrators (the Ministry of Health).

l Results

Type of facilities, geographical distribution and fundingThe data reported in this section were received from 39

facilities/organisations distributed across four regions:

Belgrade, Novi Sad, Niš and Kragujevac (Table 6). They

included 22 outpatient facilities, 13 hospital facilities

and 1 therapeutic facility reporting aggregated data for 4

therapeutic community units belonging to the same NGO.

According to the survey results, outpatient units are the

most prevalent across the country, followed by inpatient

(hospital-based) treatment units. None of the facilities

that responded to the survey identified as a low-threshold

facility, a specialised social reintegration unit or a unit for

non-hospital rehabilitation.

The Belgrade region reported 8 facilities (21 %), Novi Sad

and Niš reported 14 facilities each (36 %), and Kragujevac

reported 3 facilities (8 %). One therapeutic community

from Novi Sad provided data as a central organisation on

behalf of four therapeutic community units distributed

throughout the country and operated by the same NGO.

Regarding the distribution of treatment facilities based on

the findings from the facility survey, the Novi Sad region has

the greatest variety, including both outpatient and inpatient

units and four therapeutic communities, followed by the Niš

region, with inpatient and outpatient units, Belgrade and

Kragujevac.

TABLE 6

Number of units by region and unit type in Serbia in the 2017 WHO-UNODC facility survey





Therapeutic community unit

Other inpatient


Total

Belgrade 0 6 0 2 0 0 0 8

Novi Sad 0 4 0 6 4 0 0 14

Kragujevac 0 2 0 1 0 0 0 3

Niš 0 10 0 4 0 0 0 14

Total 0 22 0 13 4 0 0 39

Data from the four therapeutic communities were submitted as one submission in aggregated form by the main parent therapeutic community located in Novi Sad. All four therapeutic communities are operated by the same NGO.


28

FIGURE 12

Number of surveyed units by affiliation and unit type in Serbia in 2016 (WHO-UNODC facility survey, 2017)

4

13

22

�erapeutic community

Hospital

Outpatient service, ambulant service/clinic/polyclinic

Non-governmental,for pro�t (private)

Non-governmental and not-for-pro�t(NGO)

Public/governmental

Specialised social reintegration unit

Low-threshold unit

Non-hospital-based residential treatment

0

0

0

Funding from the government is received by 82 % of the

facilities; 10 % are NGOs and non-profit private facilities,

which are mainly therapeutic communities connected with

religious organisations; and 8 % are for-profit facilities,

mostly private clinics (Figure 12). Among the governmental

facilities, the Ministry of Health represents the main source

of funding, financing 74 % of the facilities (29); the Ministry

of Justice funds 10 % (4); and all the other ministries fund

15.5 % (6).

l Target population and client characteristicsDepending on the type of facility, there are differences

between the primary substances treated. In outpatient

units, clinics and polyclinics, 41 % of clients were receiving

treatment for alcohol-related disorders (Figure 13). In

hospitals, treatment for problems related to alcohol

constitutes 75 % of the services provided; in therapeutic

communities, treatment relating to drug use disorders is

the most common (68 %). There were no reports on primary

treatment for nicotine use disorders.

Overall, 7 629 people with drug use disorders were

admitted and treated in 2016 in the facilities that

responded to the survey. It should be noted that only

22 facilities out of the 39 that participated in the survey

provided data on the total number of treatment clients for

the reference period January to December 2016.

Clients who received treatment for problems relating to

use of hypnotics and sedatives accounted for the highest

proportion of clients in treatment in 2016 (44 %), followed

by opioid users, who represented 40 % of clients in

treatment (Figure 14). The number of people treated for

other drug use disorders was considerably lower. There

were 574 clients treated for cannabis use disorders, the

majority of whom were treated in hospitals. Stimulant use

disorders other than cocaine accounted for 323 clients

in 16 facilities. The majority of stimulant clients were

treated in clinics, polyclinics and therapeutic communities.

According to the facilities that participated in the survey, 55

clients sought treatment for problems relating to the use of

hallucinogenic drugs and seven people sought treatment

for problems relating to the use of inhalants. For this group,

assistance was provided in clinics and polyclinics.

FIGURE 13

Proportion (%) of clients of surveyed facilities by type of unit and type of substance use in Serbia in 2016 (WHO-UNODC facility survey, 2017)

�erapeutic communityOutpatient service/clinic/polyclinic Hospital

41 %

29 %

30 %

75 %

19 %

6 % 5 %

68 %26 %

Alcohol

Illicit drugs

Misuse of pharmaceuticals/medicines


29

FIGURE 14

Proportion (%) of clients of surveyed facilities by primary substance in Serbia in 2016 (WHO-UNODC facility survey, 2017)

40 %

9 %1 %5 %

44 %

1 %


Opioids

Cannabis

Cocaine


Dissociatives and hallucinogens

StaffingIn Serbia, 918 people are employed in the treatment of

drug and alcohol use disorders, a full time equivalent (FTE)

of 706 staff. The number of staff providing non-medical

services is 330 FTE in over 15 facilities. A notably small

number of field workers, community health workers and

pharmacists were reported, which could be due to the lack

of low-threshold agencies participating in the survey.

The staff employed in drug treatment facilities are mainly

medical specialists, and a small number of facilities report

that volunteers work for them. General medicine nurses/

technicians are the most numerous type of staff, followed

by general psychiatrists and medical doctors specialised in

psychiatry or addiction medicine (Figure 15). There are 104

(69.5 FTE) general psychiatrists in 26 facilities, 23 (15.25 FTE)

specialists in addiction medicine in 21 facilities, 39 (20.8 FTE)

psychologists in 25 facilities and 225 (146 FTE) psychiatric

medical nurses in 26 facilities. The number of social workers

is 26 (13.1 FTE) in 21 facilities. Data on the number of

volunteers were reported by 17 facilities; there were seven

volunteers (all full-time) across all regions.

Provision of services and quality assuranceThe findings show that the provision of opioid agonist

maintenance treatment for people experiencing opioid-

related problems is available in all regions of Serbia.

Twenty-six units provided this treatment to 3 247 clients

across Serbia during the reference period. There were 273

clients (8.4 %) treated with opioid agonist maintenance

treatment in the Belgrade region (6 units); 897 clients

treated (28 %) in Novi Sad (6 units); 966 clients treated

(31 %) in Kragujevac (2 units); and 1 111 clients treated

(34 %) in the Niš region (12 units). Detoxification

programmes were found to be available in 34 out of the 39

facilities that participated in the survey.

FIGURE 15

Staffing (FTE) by category of professionals among surveyed facilities in Serbia in 2016 (WHO-UNODC facility survey, 2017)

1

1

1

2

7

23

26

32

38

39

44

45

104

225

330

Nursing assistants

Community health workers

People not providing treatment (volunteers)

Pharmacists

Volunteers

Medical doctors specialised inpsychiatry or addiction medicine

Social workers

Other professionals (degree level)

Addiction/psychiatric nurses

Psychologists

Other treatment personnel (ex-patients, lay health workers, etc.)

Medical doctors not specialised inpsychiatry or addiction medicine

General psychiatrists

General nurses

People not providing treatment(sta�)

In terms of psychosocial treatment options, 26 out of

39 facilities, or 67 %, provide brief psychotherapeutic

interventions, while extended psychotherapy for

longer than two weeks is provided by 74 %. Long-term

psychosocial therapy includes approaches such as

cognitive behavioural therapy in 10 facilities (26 %),

motivational enhancement therapy in 7 facilities (18 %),

family counselling in 13 facilities (33 %), individual

counselling in 5 facilities (13 %), group counselling in 11

facilities (28 %) and the 12-step facilitation technique in 2

facilities (5 %). Individual counselling is the most common

form of psychosocial assistance in outpatient and hospital

treatment.

A limited number of facilities reported the availability

of specific services for infectious disease testing and

treatment and related services; HIV testing is available in

16 out of 39 facilities, or 41 %; HCV testing is available

in 15 out of 39 facilities, or 38 %; hepatitis C treatment is

available in 7 out of 39 facilities, or 18 %; and antiretroviral

treatment is available in 4 out of 39 facilities, or 10 %.

HBV testing and treatment was not available in any of the

surveyed facilities.


30

Of the drug treatment facilities in Serbia that responded to

the questionnaire, 53 % were accredited (21 institutions),

15 % (six facilities) had not completed the accreditation

process, 23 % (nine facilities) were not accredited and

three facilities did not provide this information. Of the

outpatient treatment facilities, 59 % were accredited; 61 %

of the hospital-based facilities were accredited. None of the

therapeutic communities was accredited to work with drug

users. Of the 21 accreditations issued, 15 had been issued

by the Ministry of Health, five by the Ministry of Health

Accreditation Agency, and one by the Health Inspectorate

of the Ministry of Health. According to the Ministry of

Health, the accreditation process is under the authority

of the Health Inspectorate; however, accreditation is not

a requirement to provide treatment under the currently

enforced legislation.


The results of the WHO-UNODC Substance use disorder

treatment facility survey highlight the uneven distribution

of drug dependence treatment and care services in Serbia,

which do not cover all regions of the country. Services are

mainly offered in Novi Sad, Niš and Belgrade. For a better

understanding of the 2016/2017 WHO-UNODC Substance

use disorder treatment facility survey pilot outcomes, it is

important to take into account that the data were provided

by a limited sample (75 %) of treatment services in Serbia,

with some big institutions not participating in the study.

Drug use disorder treatment in principle is available

at the primary healthcare level in Serbia, especially

pharmacological treatment of opioid use disorders.

Health centres in Serbia offer of a variety of services for

the treatment of drug use disorders, including medical

detoxification, medication-assisted treatment (with

opioid agonists and opioid antagonists), short-term

psychosocial treatments (e.g. motivational interviewing,

individual psychosocial counselling, individual and group

psychotherapy) and long-term psychosocial treatments

(e.g. rehabilitation group and family therapy). Long-term

psychosocial therapy is provided in all hospital facilities

but only in 15 outpatient treatment facilities. The limited

provision of psychosocial treatment in outpatient clinics

and polyclinics might be explained by the excessive

workload of the doctors in these services.

The facilities that responded to the survey reported limited

availability of HIV, HBV and HCV testing. It should be noted

that in Serbia such tests are most commonly administered

in public health facilities and infectious diseases wards.

In the future, the quality of care could be improved through

targeted capacity building initiatives in the area of drug

dependence treatment and care. Additionally, there may

be a need for greater standardisation of the conditions

and rules for the accreditation of health facilities, as

well as a defined body responsible for implementing the

accreditation of drug treatment facilities and supervising

the accreditation process. It may also be necessary to

define who is authorised to accredit facilities outside

the health sector, such as therapeutic communities and

low-threshold units. These actions would contribute

to improving and harmonising the quality of drug use

treatment across all sectors dealing with the treatment and

care of drug users in Serbia.


31

Discussion and way forwardThis report highlights the complex situation regarding

drug treatment systems in the Western Balkan region.

Drug treatment systems in the region have common

organisational elements, such as general primary

healthcare centres, specialised outpatient drug facilities,

and inpatient centres at distinct levels, including university

medical centres and special psychiatric hospitals.

Furthermore, the treatment systems in the Western

Balkans are characterised by clear distinctions between

publicly funded and owned facilities and NGOs primarily

involved in the provision of harm reduction services and

OST. Although core specialised and low-threshold services

are in place in all four countries, results from the facility

surveys have shown that the geographical coverage of

available services in the Western Balkan region remains

limited, thus confirming previously published data (e.g.

EMCDDA, 2015).

Most of the public and non-governmental services are

located in major urban centres and densely populated

parts of the Western Balkan countries and have little

reach outside of these areas. As a consequence, access

to treatment for drug users seeking or in need of care is

insufficient outside urban areas. To receive care, drug users

must migrate or travel to the cities, which is particularly

problematic for several reasons. For example, clients

living outside cities and requiring daily provision of opioid

substitution medication without take-home opportunities

may be more likely to skip daily attendance or drop out

altogether. Furthermore, services catering for the needs of

users in large geographical areas are faced with a high risk

of having to operate above their actual capacity, which is

particularly true for low-threshold and outpatient services.

This challenge is compounded, as the findings from the

present surveys make clear, by the fact that the surveyed

facilities in all the participating countries lack sufficient

qualified personnel.

Expansion and scaling up of drug treatment services

nationwide is required in all the countries to provide access

to those in need. Actions in this respect might include

encouraging the greater involvement of primary healthcare

professionals, such as general practitioners and family

doctors, outside urban areas. However, primary healthcare

providers are not an integral part of national drug

treatment systems in the Western Balkan countries, with

the exception of Serbia. In addition, increased budgets to

permit the hiring of additional qualified staff are needed to

address understaffing in existing services in the countries’

capitals and large cities.

There is an emerging network of harm reduction services

in the region. NGOs and community organisations have

played a leading and fundamental role in developing HIV

prevention services for people who inject drugs. There is

a clear need, however, to scale up the provision of OST

and access to syringe exchange programmes, especially

beyond capital and larger cities. With evidence of on-going

epidemics of hepatitis C, it is also important to strengthen

community responses to HCV prevention and treatment,

given its potential impact on public health and on national

care systems. However, most of these services have until

now relied largely on the Global Fund to finance their

operations. NGOs surveyed in the facility surveys, both

in the territory of Kosovo and in Bosnia and Herzegovina,

reported the challenges of achieving sustainability and

transitioning to public funding since the Global Fund

discontinued its funding of these services in 2016.

In summary, the geographical expansion of services,

budgetary consolidation of existing services, quality

management of available core interventions and continued

investments in improving the monitoring of epidemiological

and health response-related data remain priorities and

challenges in the region.

However, the results from the treatment facility surveys

also highlighted a number of achievements across all the

participating countries. Data obtained through this exercise

provided new information on the availability of a range

of interventions, including specific programmes within

existing treatment systems for specific subgroups of drug

users seeking support for their drug problems. Thus, needs

for the development of services for women and for the

homeless drug-using population were identified in some

countries.

This first pilot of facility surveys across national treatment

systems in the Western Balkan region also contributed

to building cooperation between national stakeholders

involved in the coordination and monitoring of national

treatment systems. Furthermore, it contributed to a revision

of existing data on treatment systems and their coverage,

as well as of structural and financial information on

treatment services. In this respect, the findings can be used

to inform the further development of and adjustments to

drug policies and strategies.

The results must be viewed with caution, however, since

this was the first pilot, created to assess the feasibility of

using translated versions of the EMCDDA EFSQ and the

WHO-UNODC treatment facility survey. The comparability


32

of the results between countries is limited because of the

differences in design and methodology of the national

studies. For example, mainly public institutions were

addressed in Serbia, whereas in Albania, Bosnia and

Herzegovina and the territory of Kosovo the sampling

frame included NGOs. Furthermore, the data from Serbia

was collected in 2017 with the WHO-UNODC mapping

instrument and a different methodology, which, although

compatible with the EFSQ in many ways, may result in

differences in the data. Although the response rate in

each country was relatively high, not all existing treatment

facilities participated in the national surveys. Thus, the

current results should not be generalised as they do not

provide a sufficient basis for a full assessment of the

respective national treatment systems.

Looking to the future, the experience of this first joint

EMCDDA-WHO-UNODC exercise in piloting facility surveys

among existing structures in national treatment systems

in the Western Balkan region has proven to be successful

and provided important new data for national authorities

to take into account when planning and commissioning

services to meet the needs of high-risk drug users in their

countries. As a result, national drug monitoring agencies

are encouraged to repeat this exercise on a regular

basis while continuing their efforts to implement robust

treatment client monitoring systems across their national

treatment systems. These two data collection exercises

should be viewed as complementary parts of an overall

effort to provide the comprehensive information and

evidence necessary for informed and sound decision-

making.

In this respect, it is important that national drug monitoring

agencies provide support and incentives to the treatment

centres participating in these surveys and react in a flexible

way on the wider implementation of such data collection

exercises.


33

l References

l EMCDDA (European Monitoring Centre for Drugs and Drug

Addiction) (2015), Drug use and its consequences in the

Western Balkans 2006-14, European Monitoring Centre for

Drugs and Drug Addiction, Lisbon.

l EMCDDA (2014), Kosovo national report 2014, European

Monitoring Centre for Drugs and Drug Addiction, Lisbon.

l EMCDDA (2017a), European Facility Survey Questionnaire

(EFSQ) package, http://www.emcdda.europa.eu/publications/

technical-reports/european-facility-survey-questionnaire-

efsq_en (accessed on 25 September 2018).

l EMCDDA (2017b), IPA 5 project activities (July 2015-June 2017),

http://www.emcdda.europa.eu/about/partners/cc/ipa5

(accessed on 25 September 2018).

l EMCDDA (2017c), Albania national drug report 2017, European


l EMCDDA (2017d), Serbia national drug report 2017, European


l EMCDDA (2018a), EMCDDA country profiles, http://www.

emcdda.europa.eu/countries_en (accessed on 25 September

2018).

l EMCDDA (2018b), Bosnia and Herzegovina country overview

2017, European Monitoring Centre for Drugs and Drug Addiction,

Lisbon.

l EMCDDA and Europol (2016), EU Drug Markets Report: in-depth

analysis, Publications Office of the European Union,

Luxembourg.

l UNODC (United Nations Office on Drugs and Crime) (2018a),

World drug report 2018, United Nations Publications, Vienna.

l UNODC (2018b), Annual report questionnaire, http://www.

unodc.org/arq (accessed on 25 September 2018).

l UNODC (2018c), Drug use, https://www.unodc.org/unodc/en/

data-and-analysis/drug-use.html (accessed on 25 September

2018).

l UNODC (2018d), Publications on prevention of drug use and

treatment, care and rehabilitation of drug dependence, http://

www.unodc.org/unodc/en/drug-prevention-and-treatment/

publications.html (accessed on 25 September 2018).

l UNODC and WHO (World Health Organization) (2016),

International Standards for the treatment of drug use disorders:

draft for field testing (http://www.unodc.org/documents/

International_Standards_2016_for_CND.pdf).

l UNODC and WHO (2018), Draft for field testing: WHO/UNODC

Substance use disorder treatment facility survey (http://www.

unodc.org/documents/WHO_UNODC_Facility_survey_Draft_

for_field_testing_March_2018.pdf).

http://www.emcdda.europa.eu/publications/technical-reports/european-facility-survey-questionnaire-efsq_en



http://www.emcdda.europa.eu/about/partners/cc/ipa5

http://www.emcdda.europa.eu/countries_en

http://www.emcdda.europa.eu/countries_en

http://www.unodc.org/arq

http://www.unodc.org/arq

https://www.unodc.org/unodc/en/data-and-analysis/drug-use.html

https://www.unodc.org/unodc/en/data-and-analysis/drug-use.html

http://www.unodc.org/unodc/en/drug-prevention-and-treatment/publications.html



http://www.unodc.org/documents/WHO_UNODC_Facility_survey_Draft_for_field_testing_March_2018.pdf



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About this publication

This report presents a summary of the key findings from drug

treatment facility surveys carried out in 2017 in Albania, Bosnia

and Herzegovina, Serbia and the territory of Kosovo. The results

provide insight into the characteristics and capacity of the

treatment systems, as well as the availability and provision of

treatment interventions. The report also considers the

implications for practice and policy.

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction

(EMCDDA) is the central source and confirmed authority on

drug-related issues in Europe. For over 20 years, it has been

collecting, analysing and disseminating scientifically sound

information on drugs and drug addiction and their

consequences, providing its audiences with an evidence-based

picture of the drug phenomenon at European level.

The EMCDDA’s publications are a prime source of information

for a wide range of audiences including: policymakers and their

advisors; professionals and researchers working in the drugs

field; and, more broadly, the media and general public. Based in

Lisbon, the EMCDDA is one of the decentralised agencies of the

European Union.

About UNODC

UNODC, the United Nations Office on Drugs and Crime, is the

United Nations Secretariat entity responsible for supporting

Member States in their efforts to address drugs and crime.

UNODC’s work on prevention and treatment of drug use

disorders includes also the support for the development of drug

information systems to support the planning of adequate

prevention and treatment services. Established in 1997 through

a merger between the United Nations Drug Control Programme

and the Centre for International Crime Prevention, UNODC

operates in all regions of the world through an extensive network

of field offices and provides technical assistance to UN Member

States.

drug treatment systems in western balkan countries · candidate countries to the eu in the western...

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